Agency Referrals

Please complete our online Agency Referral form below to register your client with us. Alternatively you can download a Microsoft® Word version here to complete and post or fax back to us using our contact details at the bottom of the page.

If you’d prefer to have a chat with us about our services, please call us on 0131 315 4466 or email referrals@pepscot.org

Please note that we are unable to register group members with a dementia diagnosis or personal care needs. We apologise for any inconvenience caused.

    Agency Referrals

    Complete the form below to enquire about volunteering.
    Fields marked with an asterisk (*) are required.

    Referrer details






    Please provide an email in the field below so we can send you a confirmation message with the details you have provided for reference:

    How long have you known the client?

    Characters remaining: 300

    Client details





    If you selected 'Other' from the options above, please specify in the field below:


    If you selected 'Other' from the options above, please specify in the field below:

    Emergency details

    GP contact details


    Other details

    Characters remaining: 300

    Characters remaining: 300

    Characters remaining: 1000

    Medical information

    Characters remaining: 300


    If you selected 'Other' from the options above, please specify in the field below:


    Characters remaining: 300

    Characters remaining: 300

    Reason for referral

    Characters remaining: 1000